Geriatric Case 3: Termination of Resuscitation

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This case is the third in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why it Matters

Deciding when to terminate CPR is a very delicate moment in a patient’s care. It is literally the determination of possible life vs. certain death. There are clear guidelines for when to terminate resuscitation in certain contexts, but for patients who are brought to the ED by EMS, there is no true objective measure of when to terminate CPR. This is where determination of quality of life is important. In the elderly, the likelihood of a meaningful quality of life after a CPR-requiring event is quite low. Recognizing this futility is an important and challenging skill to learn. Being able to debrief with your team and discuss these events further is another essential skill that is often not practiced. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

ED RN to inform team prior to patient’s arrival: “We have an out of hospital cardiac arrest coming in with an unknown downtime and unknown past medical history. He is an 89-year-old male coming from home. He has had no shocks and CPR is in progress. They are one minute away.”

Case Summary

An elderly male is brought in by ambulance from home with CPR in progress. He collapsed in front of his son/daughter who commenced CPR. His rhythm has been PEA throughout and his downtime is 20 minutes. Participants should assess the patient, gather information about his background and determine that CPR is futile. They should decide to cease CPR and inform his son/daughter in a sensitive manner that their father has died. They will also debrief the team following the termination of resuscitation.

Download the case here: Geri EM Termination of Resuscitation

U/S for the case found here:

(U/S courtesy of McMaster PoCUS Subspecialty Training Program)

Geriatric Case 2: Chronic Digoxin Toxicity

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This case is the second in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia.Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why it Matters

This case demonstrates several diagnostic challenges that can occur with the bradycardic patient on digoxin including:

  • The need to resuscitate the patient appropriately (and thus, empirically treat) while waiting on labs to confirm whether hyperkalemia or digoxin is the culprit
  • The theoretical concern of administering calcium for correction of hyperkalemia (because we usually have a potassium result back before the digoxin level)
  • The need to consider precipitating causes of a patient’s presentation

Clinical Vignette

To be stated by the bedside nurse: “Bertie is an 85-year-old man who has been brought in after a fall at home. He says he is feeling dizzy and has a HR of 30 on the monitor. I haven’t had much of a chance to take more of a history from him but he has a list of medications with him and seems ok from the fall other than a bruise on his head.”

Case Summary

An 85-year-old man presents after a fall at home. He is complaining of dizziness and has a HR of 30. Further assessment reveals chronic digoxin toxicity and a concurrent UTI with acute renal failure. The patient requires management of his bradycardia and acute renal failure with specific management of chronic digoxin toxicity including a discussion with toxicology and administration of Digibind.

Download the case here: Geri EM Chronic Digoxin Toxicity

ECG for the case found here:

(ECG source: http://www.ems12lead.com/wp-content/uploads/sites/42/2014/01/digitalis_ECG.jpg)

CXR for the case found here:

normal cxr

(CXR source: https://radiopaedia.org/images/220869)

 

Geriatric Case 1: Delirium

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This case is the first in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Victoria Brazil, Nemat Alsaba, and Rebecca Shaw.

Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com). Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia.

Why it Matters

As our global patient population ages, it is increasingly important that emergency physicians have specialized knowledge in the care of elderly patients. This is particularly true when managing patients with baseline dementia or presenting to the ED with delirium. This case highlights specific challenges in these patients, including:

  • The need to recognize delirium as symptom of a large array of potential medical illnesses
  • The importance of a medical work-up in patients with delirium (including blood work, urine, and possible imaging)
  • The need for health care workers to have a toolbox of de-escalation techniques at their disposal

Clinical Vignette

Patient is sitting on the edge of the ED bed, looking perplexed. She/he is fidgeting and not concentrating on the questions being asked, she/he is staring around the room, looking in his/her bag and picking at the BP cuff and bed sheet. The ED nurse is attempting to do some baseline vital signs on the patient.

Participants asked by ED RN “Could you please go and assess this patient? She/he has just been brought in to the ED by ambulance after a friend found her/him confused at home”

Case Summary

An 81-year-old (wo)man is brought to the ED by her/his friend as she/he is confused and agitated. In the ED, her/his confusion worsens. Initially she/he is fidgety but as the case progresses she/he becomes more agitated and confused. She/he will be fairly uncooperative, moving around and not able to follow many commands. The participants should be looking for a source of infection and evidence of any recent trauma.  They are expected to use both non-pharmacological and safe pharmacological options in order to control the situation, ensure patient safety, and facilitate investigations.

Download the case here: Geri EM Delirium

LVAD Case

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This week’s case is written by Drs. Ashley Lubberdink and Sameer Sharif. Dr. Lubberdink is a PGY4 Emergency Medicine resident at McMaster University and is just beginning her fellowship in simulation and medical education. Dr. Sharif is a PGY5 Emergency Medicine resident at McMaster University who has just completed his fellowship in simulation and medical education.

Why it Matters

LVADs are pretty uncommon devices! If your practice location is not a hospital that inserts LVADs, then it is likely that you have never come across a patient with an LVAD. Without prior knowledge of these devices, it can be quite distressing trying to assess these patients. This case is designing to highlight the following:

  • LVAD patients do not have a pulse, a measurable blood pressure, or a detectable heart rate on the sat probe
  • To assess for blood pressure, one must insert an arterial line or use a blood pressure cuff and doppler U/S to obtain the MAP
  • Early after LVAD placement, drive line infection and bleeding are common complications
  • Call for help early! These patients generally have care providers who are available to help trouble shoot by phone at all hours of the day

More Reading

For more information on an approach to LVADs, we suggest the following sources:

https://emcrit.org/emcrit/left-ventricular-assist-devices-lvads-2/

https://canadiem.org/lvads-approach-ed/

Clinical Vignette

A 62-year-old male presents to your large community ED with a 1 day history of generalized malaise and nausea and a 2-hour history of palpitations. He is particularly concerned about his symptoms because last month he had an LVAD placed at your provinces’ major cardiac center (3 hours away) for stage 4 CHF. His wife is accompanying him but is currently parking the car.

Case Summary

A 62-year-old man presents to the ED with palpitations and general malaise. On initial assessment, the team finds out he had an LVAD placed within the last 1 month. The team will need to work through how to assess the patient’s vital signs appropriately and will discover the patient has a low MAP and a low-grade fever. On inspection, the patient’s drive line site will appear infected. The initial ECG will show features of hyperkalemia. After the initial assessment, the patient will progress to a PEA arrest requiring resuscitation by ACLS protocols. Labs will reveal an acute kidney injury and hyperkalemia. The patient will obtain ROSC when the hyperkalemia is treated.

Download the case here: LVAD Case

Initial ECG for the case found here:

hyperkalemia

(ECG source: https://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

Second ECG for the case found here:

hyperkalemia narrow QRS

(ECG source: https://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

CXR for the case found here:

LVAD-CXR

(CXR source: https://edecmo.org/additional-technologies/ventricular-assist-devices-vads/lvads/)

Picture of drive line site infection found here:

driveline infection A

(Picture source: http://journals.sagepub.com/doi/full/10.1177/1179065217714216)

Echo for case found here:

(Echo source: https://www.youtube.com/watch?v=-4ThAo4m2UI)

Polytrauma for Team Communication

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This case is written by Dr. Chris Heyd. He is a PGY4 Emergency Medicine resident at McMaster University and has spent the last year completing a sub-specialty focus in disaster medicine and simulation. He is also one of our resident editors here at EmSimCases.

Why it Matters

This case highlights some of the challenges that can be associated with activating a trauma team. While the intent is to have many expert hands available to help at once, sometimes the team members arrive in a staggered fashion. This case reviews:

  • The challenges of managing an unstable trauma patient when there are interruptions to the flow of communication
  • The need to expediently place a chest tube in a hypoxic trauma patient
  • The fact that near simultaneous intubation and chest tube placement is often necessary in an unstable trauma patient

Clinical Vignette

To be read aloud by simulation facilitator at start of case:

“You are working as an Emergency physician at a tertiary care trauma centre and have been called overhead to your trauma bay. A paramedic team has just arrived with a 64-year old trauma patient. He was involved in a highway speed head-on MVC. He was restrained and air bags deployed. He was the driver and the other drive died on scene. There were no other passengers. EMS extricated the patient easily. They have placed one IV line and started running normal saline. He has been placed on a non-rebreather mask but has remained tachycardic, hypoxic and altered. GCS has been consistently 14. The trauma team was activated based on injury mechanism but so far only the orthopedic resident has arrived at the bedside.”

Case Summary

A 64-year old man is involved in a high-speed car crash. The trauma team is activated and he is brought directly to the ED. On arrival, he is hypoxic, tachycardic and altered. CXR reveals multiple rib fractures with a right-sided hemopneumothorax.

The team leader will need to effectively communicate with the team to ensure the tasks of intubation, chest tube placement and blood product administration are performed in a safe and quickly. The patient will stabilize after these treatments.

Members of the trauma team will have a staggered entry into the room. The team leader will need to balance communication with the new team members and the urgent interventions needed by the patient.

Download the case here: Polytrauma for Team Communication

CXR for the case found here:

CXR trauma

(CXR source: https://radiopaedia.org/cases/large-traumatic-haemothorax)

PXR for the case found here:

Normal PXR

(PXR source: https://radiopaedia.org/cases/normal-pelvis-x-ray-trauma-supine-1)

Lung U/S showing hemothorax found here:

 

(U/S source: McMaster PoCUS Subspecialty Training Program)

Normal RUQ FAST image found here:

no FF

(U/S source: McMaster PoCUS Subspecialty Training Program)

Pregnant Cardiomyopathy

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This case is written by Drs. Nadia Primiani and Sev Perelman. They are both emergency physicians at Mount Sinai Hospital in Toronto. Dr. Primiani is the postgraduate education coordinator at the Schwartz/Reisman Emergency Centre. Dr. Perelman is the director of SIMSinai.

Why it Matters

Most emergency physicians have some degree of discomfort when a woman in her third trimester presents to the ED for any complaint. When that woman presents in acute distress, the discomfort is increased even further! This case takes learners through the management of a patient with a pregnancy-induced cardiomyopathy, reviewing:

  • The importance of calling for help early
  • The fact that all pregnant patients at term must be presumed to have difficult airways
  • That the treatment of the underlying medical condition is still the primary focus – in this case, BiPap, definitive airway management, and ultimately, inotropic support

Clinical Vignette

You are working in a community ED and your team has been called urgently by the nurse to see a 38 year old female who is G2P1 at 36 weeks gestational age. She was brought in by her sister, who is quite agitated and upset, saying “everybody has been ignoring her symptoms for the last 4 weeks.” The patient has just experienced a syncopal episode at home.

Case Summary

A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.

Download the case here: Pregnant Cardiomyopathy

ECG for the case found here:

(ECG source: https://lifeinthefastlane.com/ecg-library/dilated-cardiomyopathy/)

 CXR for case found here:

posttestQ2pulmonaryedema

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/postquestions/posttest.html)

Cardiac Ultrasound for the case found here:

ezgif.com-optimize+(6)

(U/S source: http://www.thepocusatlas.com/echo/2hj4yjl0bcpxxokzzzoyip9mnz1ck5)

Lung U/S for the case found here:

Confluent+B+Lines

(U/S source: http://www.thepocusatlas.com/pulmonary/)

RUQ FAST U/S Image found here:

usruqneg

(U/S source: http://sinaiem.us/tutorials/fast/us-ruq-normal/)

OB U/S found here:

(U/S source: https://www.youtube.com/watch?v=SKKnTLqI_VM)

Pediatric SVT

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This case is written by Drs. Laura Simone and Olivia Ostrow. They are both Pediatric Emergency Physicians at Toronto’s Sick Kids Hospital.

Why it Matters

SVT is the most common pediatric dysrhythmia that we see in the ED after sinus tachycardia. But sometimes, in very young children and infants, it can be hard to distinguish the two! This case highlights some important features of the management of SVT, including:

  • The need for an ECG when they heart rate is very high
  • The role of vagal maneuvers as a first attempt at cardioversion
  • The dosing of adenosine and electricity for cardioversion of SVT

Clinical Vignette

A 12-month old male is brought into your ED today by his parents because he has been fussy, crying all night and not feeding well today. He had emesis x 1 (non-bilious, non-bloody). At triage, the RN had difficulty recording the heart rate but by auscultation it seemed “quite rapid” and he “feels a bit warm”.

Case Summary

The team has been called to the ED after a 12-month old is brought in with a rapid heart rate. The team will realize the patient is in a stable SVT rhythm, with no response to either vagal maneuvers or adenosine. The patient will then progress to having an unstable SVT. If the SVT is defibrillated (i.e. – shocked without synchronization), the patient will progress to VT arrest. If the SVT is cardioverted, the patient will clinically improve.

Download the case here: Pediatric SVT

Initial ECG for the case found here:

SVT

(ECG source: http://hqmeded-ecg.blogspot.ca/2013/01/heart-rate-of-230-beats-per-minute.html)

Post-Cardioversion ECG for the case found here:

normal-sinus-rhythm (1)

(ECG source: http://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)

VT ECG for the case found here:

VT

(ECG source: https://lifeinthefastlane.com/ecg-library/ventricular-tachycardia/)

 

Palliative Respiratory Case

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This case is written by Dr. Alexandra Stefan. Dr. Stefan is an emergency medicine physician and the Postgraduate Site Director for Emergency Medicine at Sunnybrook Health Sciences Centre in Toronto. She is also an assistant professor in the Division of Emergency Medicine at the University of Toronto. Her areas of interest are postgraduate medical education, simulation (has completed the Harvard Centre for Medical Simulation training course) and global health  education (has participated in teaching trips with Toronto Addis Ababa Academic Collaboration).

Why it Matters

Emergency medicine training is often focused on the many interventions we can make when a patient arrives in distress. This case highlights that sometimes, one of the most important interventions is to determine a patient’s goals of care. It specifically highlights:

  • The importance of pain management as a part of end of life care
  • The need to speak clearly and without medical jargon to establish a patient’s wishes
  • That goals of care conversations often happen in the ED through a substitute decision maker, rather than with the patient directly.

Clinical Vignette

“A 72 year old man from home with acute shortness of breath has just been placed in the resuscitation room. He has a history of lung cancer and is on 2L home oxygen. His daughter Cindy called 911 because he has been getting worse since this morning. He just finished a course of antibiotics for presumed pneumonia. He is on hydromorph contin and prochlorperazine. No allergies. Here is his most recent oncology clinic note.”

Case Summary

A 72-year old male with small cell lung cancer and bony metastases presents with acute shortness of breath. Curative treatment has been stopped and palliative care assessment is pending. He is on home oxygen and has come to the ED as his symptoms could not be controlled at home.

The patient initially improves with oxygen and pain control. He is too confused to engage in discussion about advanced directives. No previous advanced directives or level of care have been documented but, Cindy, the patient’s daughter is available to act as decision maker. She will have a number of questions about her father’s care.

The patient’s respiratory status will deteriorate. Cindy will confirm her father’s wish for comfort measures, to be started by the treating team.

Download the case here: Palliative Resp Case

Download the clinic note required for the case here: Med Onc Note

ECG for the case found here:

ecg sob case

(ECG source: http://www.thecrashcart.org/case-2-post-partum-palpitations/)

CXR for the case found here:

pleural effusion

(CXR source: https://radiopaedia.org/cases/pleural-effusion-7)

Cardiac Ultrasound for the case found here:

 

(U/S image courtesy of McMaster PoCUS Subspecialty Training Program.)

Learner-Consultant Communication

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This case was written by Dr. Jared Baylis. Jared is currently a PGY-4 in emergency medicine at UBC (Interior Site – Kelowna, BC) and is completing a simulation fellowship in Vancouver, BC.

Twitter – @baylis_jared + @KelownaEM

Why It Matters

Referral-consultant interactions occur with regularity in the emergency department. These interactions are critically important to safe and effective patient care. Several frameworks have been developed for teaching learners how to communicate during a consultation including the 5C, PIQUED, and CONSULT models. This case allows simulation educators to incorporate whichever consultation framework they prefer into a simulation scenario that allows deliberate practice of the consultation process.

Clinical Vignette

You are a junior resident working in a tertiary care centre and you are asked to see a 58-year-old female patient who was sent in from the cancer centre. She is known to have metastatic non-small-cell lung cancer and has been increasingly dyspneic with postural pre-syncope over the last few days. Her history is significant for a previous malignant pericardial effusion that was drained therapeutically a few months ago.

Case Summary

In this case, learners will be expected to recognize that this 58-year-old female patient with metastatic non-small-cell lung cancer has tamponade physiology secondary to a malignant pericardial effusion. The patient will stabilize somewhat with a gentle fluid bolus but the learners will be expected to urgently consult cardiology or cardiac/thoracic surgery (depending on the centre) for a pericardiocentesis and/or pericardial window.

Download the case here: Learner-Consultant Communication

Checklists for 5C, PIQUED, and CONSULT frameworks: Consult Framework Checklists

FOAMed article on 5C framework: 5C CanadiEM

FOAMed article on PIQUED framework: PIQUED CanadiEM

ECG for the case found here:

ECG

(ECG Source: https://lifeinthefastlane.com/ecg-library/basics/low-qrs-voltage/)

CXR for the case found here:

CXR

(CXR Source: https://radiopaedia.org)

POCUS for the case found here:

 

(Ultrasound Source: https://www.youtube.com/watch?v=qAlU8qhC1cU)

Elderly Psychosis and Agitation

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This case is written by Drs. Nicole Kester-Green and Jen Riley. Dr. Kester-Greene is a staff physician at Sunnybrook Health Sciences Centre in the Department of Emergency Services and an assistant professor in the Department of Medicine, Division of Emergency Medicine. She has completed a simulation educators training course at Harvard Centre for Medical Simulation and is currently Director of Emergency Medicine Simulation at Sunnybrook. Dr. Riley is a staff emergency physician at St. Michael’s Hospital and assistant professor at the University of Toronto.  Her areas of interest are in simulation and medical technology, with a focus on developing programs and curriculum for trainees and faculty both in medicine and allied health professions.

Why it Matters

Patients who present to the ED with agitation can be very challenging to manage. It is particularly difficult when the patient clearly lacks capacity and is unable to respond appropriately to any simple commands. In these situations, ensuring the safety of both the patient and staff members becomes the primary goal. This case highlights, specifically:

  • That chemical restraint should always be used if physical restraints are to be used
  • The challenges to assessing a patient who is clearly unwell when that patient is not cooperative
  • The role security plays in ensuring a safe patient care experience

A Note on Safety

Pre-briefing is always an important component of simulation. For this case, it is essential that the pre-briefing takes a little extra time so that the safety of everyone involved is reviewed. The case is designed so that physical restraints are only placed once the standardized patient is traded for a mannequin. Regardless, both the standardized patient and the sim participants should be briefed on the use of simulated restraint. It is essential that a safe word like “time out” is pre-determined in case any participants are feeling unsafe at any point in the case. This would immediately halt the case. Similarly, instructors must be watching closely for safety and cut the scenario if they feel anyone may be harmed. We advocate for having security participate in this case as learners. However, briefing security that they should not use the restraints on the standardized patient would also help ensure safety.

Clinical Vignette

The charge nurse comes to you: “There is a 68 year old woman in the seclusion room. She was observed pacing and acting bizarre at the bus stop. EMS managed to talk her into ambulance. On route she told them her neighbour is trying to poison her. Initially, she was calm but now she is starting to get agitated. She doesn’t have any previous psych admissions in the system. We couldn’t get any vital signs.

Case Summary

A 68-year old woman is found at a bus stop exhibiting bizarre behaviour. She is brought to the ED by paramedics. In the ED, she is expressing paranoid delusions. Her agitation escalates and does not respond to verbal de-escalation or an overwhelming show of force. She will require physical and chemical sedation to facilitate the work-up for her new onset psychosis.

Download the case here: Elderly psychosis and agitation

ECG for the case found here:

normal-sinus-rhythm

(ECG source: https://lifeinthefastlane.com/ecg-library/normal-sinus-rhythm/)